I, as the of , age , ofthe sex, born in , on ,do hereby voluntarily and unconditionally surrender to thecare and custody of for the purpose of adoption orsuch other disposition as may be made by a court of competent jurisdiction. I waive notice of anylegal proceeding affecting the custody, guardianship, adoption or other disposition of .I UNDERSTAND THAT THIS SURRENDER IS FINAL AND CANNOT BE REVOKED.Signature:On this day of , , before me personally came andappeared and in my presence duly executed the foregoinginstrument, and (he, she) acknowledged to me that (he, she) executed the same as (his, her) freeact and deed, fully cognizant of its irrevocability.DateState ofNotary PublicCounty ofSigned by as (his, her) freely executed consent in thepresence of each of us, and of each other, who thereafter have hereunto signed our names aswitnesses. 1)2)WRITTEN CONSENT PURSUANT TO M. G. L. c. 210, 247 2[VOLUNTARY AND UNCONDITIONAL SURRENDER](type or print - complete in triplicate)(relationship to child: mother/father)(name of child)(male/female)(place of birth)(date of birth)(name of child)(name of child)(agency or person receiving custody)(person giving consent) (day)(month)(year) (Witness No. 1 Signature)(person giving consent)(Witness No. 2 Signature)(Address)(Address) American LegalNet, Inc. www.FormsWorkFlow.com